Clinical benefits and controversies of jejunostomy feeding in patients undergoing gastrectomy for gastric cancer

Abstract

Globally, gastric cancer ranks as the fifth most common malignancy and the third leading cause of cancer-related mortality. Gastrectomy combined with perioperative chemotherapy is currently the standard of care in locally advanced stages, but the completion rate of multimodal approach is influenced also by patient related factors. Malnutrition is a well-known risk factor associated with poor oncological outcomes. Its perioperative supplementation could lead to an improvement of the nutritional status. This article reviews and comments the retrospective study conducted by Jaquet et al, which evaluates the impact of enteral nutrition by jejunostomy feeding in patients undergoing gastrectomy for cancer. The authors included 172 patients, 35% of whom received jejunostomy. Patients with optimized biological nutritional parameters (body mass index, albumin, prealbumin) showed reduced major complications (> III), according to the Dindo-Clavien classification, 0 (0%) vs 8 (4.7%) (P = 0.05). In the era of multimodal treatment, optimization of nutritional and performance status is integral part of the therapeutic strategy.

Key Words: Gastric cancer; Feeding jejunostomy; Malnutrition

Core Tip: Malnutrition is a widely recognized risk factor linked to unfavorable oncological outcomes. Enteral nutrition has many advantages, including immune and intestinal mucosa support, avoidance of bacterial translocation, and decreased risk of venous catheter infection. With perioperative chemotherapy now established as the standard treatment for advanced gastric cancer, the discussion about the benefits of jejunostomy placement for nutritional support during diagnostic exploratory laparoscopy or major surgical procedures remains particularly pertinent.

TO THE EDITOR

Every year, around 990000 people are diagnosed with gastric cancer worldwide, of whom approximately 738000 died. Gastric cancer is the fourth most common incident cancer[1]. According to recent statistics, presenting the estimated new cancer cases and deaths in the United States in 2024, around 26.500 new cases of gastric cancer and about 10.000 cases of estimated deaths were recorded[2]. Gastric cancer is the third most common cause of cancer mortality worldwide[1,3,4]. The incidence rate rises progressively with age with a median age at diagnosis is 70 years. However, approximately 10% of gastric carcinomas are detected at the age of 45 or younger[1].

Risk factors for the condition include Helicobacter pylori infection, age, dietary habits and methods of food preservation[5,6]. Improvements in understanding of the complexity of cancer biology have been instrumental in advancing cancer treatments. Oncogenic alterations have multiple effects, including increase in proliferative signaling, resistance to cell death, bypassing replicative limit, increase in genome instability[7]. Gastric cancer is mainly diagnosed histologically after endoscopic biopsy and staged using computer tomography, endoscopic ultrasound, positron emission tomography, and laparoscopy[8].

Locally advanced gastric cancer is treated with perioperative chemotherapy and adequate radical surgery including D2 lymphadenectomy for patients who are able to tolerate a triple cytotoxic drug regimen[9,10]. In locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma, perioperative 5-FU/Leucovorin/Oxaliplatin/Docetaxel regimen improved overall survival compared with perioperative epirubicin/cisplatin/fluorouracil or capecitabine[10,11].

Beyond therapeutic strategies, malnutrition in patients with diagnosed gastric neoplasm and its treatment strategies remain a common clinical matter and a debated issue.

Nutritional update

Fasting and malnutrition cause intestinal atrophy, immune barrier disruption and promotes bacterial translocation leading to higher postoperative complication rate and poor prognosis[12-14]. Total parenteral nutrition remains widely adopted in postoperative timing, should though be limited to those patients where no other nutritional supplementation is possible[15,16]. In the preoperative context, oral or enteral feeding is well established as the preferred method of nutritional support. Additionally, surgical strategies and postoperative management should account for the patient's nutritional profile[10,17-20].

On this theme different approaches are proposed between western and eastern countries. Enhanced recovery after surgery protocols for upper gastrointestinal (UpperGI) surgery recommend oral nutrition from the first postoperative day[21]. Japanese Guidelines suggest a delayed introduction of oral intake, with solid diet beginning from postoperative day 2 to 4[22]. Currently, diverse controversies regarding the real advantages of early oral nutrition exist in the current literature, with authors publishing no anastomotic leakage rate increased with early oral nutrition[23] and Japanese randomized control trials demonstrating no differences in hospital stay with delayed oral intake[24,25]. Surgical planning could also contribute reducing postoperative malnutrition. Recently, double tract reconstruction was described as a novel technique allowing in selected cases to avoid total gastrectomy with the aim of maintaining better long term nutritional outcomes[26].

Feeding jejunostomy

Malnutrition is an well known risk factor raising morbidity and mortality rates among UpperGI cancer patients[27-29]. The placement of a feeding jejunostomy tube at the time of gastrectomy offers supplementary nutritional access, which may serve to ensure enteral access for meeting caloric needs, particularly in anticipation of the significant gastrointestinal side effects during adjuvant therapy. In order to permit a patient to complete treatment, the National Comprehensive Cancer Network currently recommends that a placement of jejunostomy to be considered for patients receiving postoperative adjuvant therapy[30].

A study on patients undergoing an oesophagectomy for cancer, elaborated the question if immediate postoperative enteral feeding (via percutaneous jejunostomy or nasojejunostomy) provides better patient outcomes as compared to waiting until oral feeding can be instituted. Both methods were equally effective in providing postoperative nutrition. All included trials concluded that routine postoperative enteral nutrition was feasible, but there was no evidence suggesting that it conferred any clinical benefits[31]. The retrospective study performed by Jaquet et al[20], demonstrated a significant positive impact of postoperative enteral nutrition via jejunostomy on some complications. Enterally fed patients had a decreased rate of infectious complications, respiratory complications and grade III complications according to the Dindo-Clavien classification. Additionally, the postoperative nutritional status was better in patients fed via jejunostomy, regarding weight loss and albumin decrease. To date there are no large-scale randomized clinical trials or meta-analyses available on the topic, nevertheless the indication to supplement malnourished patients by enteral nutrition in the perioperative period is established in several international guidelines[19,21,30]. A large United States retrospective multicentric study with primary outcome focused on rate of postoperative complications and completion of adjuvant therapy reported an increased rate of infectious complications including anastomotic leakage with no increased receipt of chemotherapy in patients undergoing gastrectomy and jejunostomy placement. Of 837 patients, 265 (32%) received a jejunostomy tube. Patients receiving a jejunostomy demonstrated greater incidence of preoperative weight loss, lower body mass index (BMI), greater extent of resection, and more advanced TNM stage. The jejunostomy placement was associated with increased infectious complications (36% vs 19%, P < 0.001), including surgical-site (14% vs 6%, P < 0.001) and deep intra-abdominal (11% vs 4%, P < 0.001) infections. Jejunostomy remained an independent risk factor even after multivariate analysis and subset analysis stratified by operation type (total and subtotal gastrectomy)[32]. Contrasting findings were reported in the propensity-matched analysis by Sun et al[33], which retrospectively examined a large cohort of patients undergoing gastrectomy and jejunostomy placement for cancer. The study found no significant increase in morbidity or mortality rates within 30 days, supporting early enteral nutrition as a safe clinical practice. One possible explanation is the significantly lower rate of intra-abdominal leaks following gastrectomy (approximately 1%), compared to the higher rates observed in esophagectomy (around 12%) and pancreaticoduodenectomy (about 13%). This difference may explain why a jejunostomy placement does not appear to elevate morbidity in gastrectomy patients[33]. Concerning the esophageal surgery field, there is little support by statistical data despite the diffuse feeding jejunostomies placement in the clinical routine. A summary of four different randomized control trials on the topic reported no differences in terms of anastomotic leakage and postoperative complications in patients receiving jejunostomy during radical surgery[31].

The decisional process and the correct indication become even more complex in the era of perioperative chemotherapy. Explorative laparoscopy is standardized in most staging workups regarding patients potentially eligible for perioperative multimodal treatment[34].

Jejunostomy placement during staging laparoscopy was proposed attempting to give nutritional support during the perioperative time. This technique results safe with no major complications despite a low rate of minor complications including catheter displacement, local cutaneous erosion, wound infection, pericatheter leak or occlusion with generalized peritonitis, aspiration pneumonia, small bowel necrosis, small bowel obstruction, pneumatosis intestinalis, abdominal wall infection, fistula and volvulus[35]. Currently few retrospective studies with small numbers report low complication rates deeming the technique safe; however, long-term data are lacking to establish a real benefit in terms of improved nutritional status, adjuvant therapy completion rate, and oncologic outcomes. Further studies are needed to validate the technique and standardize its use[35].

CONCLUSION

Enteral nutrition has many advantages over intravenous nutrition, including immune and intestinal mucosa support, avoidance of bacterial translocation, and decreased risk of venous catheter infection. The article “Benefits of jejunostomy feeding in patients who underwent gastrectomy for cancer treatment” by Jaquet et al[20] supports the placement of jejunostomy in gastric cancer patients showing fewer complication rates[20]. Patients obtaining jejunostomies had more often advanced tumors requiring a total gastrectomy, a longer hospital stay, lower BMI and a greater incidence of weight loss. This shows an evident selection bias, intrinsic in the retrospective design of the study which could possibly be mitigated by a propensity matched analysis. No differences in terms of anastomotic leak rate or long-term oncological outcomes were found, according to the current literature.

Especially in the West, due to the absence of screening protocols, gastric cancer is often late diagnosed with advanced local extension of disease. In this context, patients often present with severe malnutrition and sarcopenia related to mechanical (dysphagia, reduced caloric intake) and metabolic mechanisms. In the era of perioperative chemotherapy as the standard of care in the treatment of advanced gastric cancer, the debate regarding the advantages of jejunostomy placement for nutritional purposes during diagnostic exploratory laparoscopy or demolitive surgery is highly relevant. Further larger randomized controlled trials with standardized protocols and long-term follow-up studies are needed to confirm and validate these results.

ACKNOWLEDGEMENTS

We are in debt to the staff members of the teams involved in all aspects of surgical oncology at the Department of General and Pediatric Surgery, Bolzano.